54163-2017 break free slides brown mcachran edits 110317 · 2017-11-13 · 11/6/2017 3 intro to...

11/6/2017

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w w w . v o i c e s f o r p f d . o r gt w i t t e r. c o m / V o i c e s f o r P F Dw w w. f a c e b o o k . c o m / V o i c e s f o r P F D

BREAK FREE from Pelvic Floor Disorders

w w w . v o i c e s f o r p f d . o r gt w i t t e r . c o m / V o i c e s f o r P F Dw w w . f a c e b o o k . c o m / V o i c e s f o r P F D

W E LC O M E & I N T RO D U C T I O N

Heidi Brown, MD, MAS

Sarah McAchran, MD

Dobie Giles, MD, MS

Christine Heisler, MD, MS

Angie Sergeant, NP

UW Hospital and Clinics Gynecology Clinic 608‐263‐6240

Urology Clinic 608‐263‐4757

Meriter1 South Park 608‐

287‐2900

Women’s Pelvic Wellness Clinic608‐263‐8264

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• INTRODUCTION TO PELVIC FLOOR DISORDERS

• RISK FACTORS FOR PFDS—SOME YOU CAN CONTROL

• PELVIC ORGAN PROLAPSE

• URINARY INCONTINENCE

• ACCIDENTAL BOWEL LEAKAGE

• ABOUT VOICES OF PFD

• QUESTIONS AND ANSWERS

PROGRAM OVERVIEW

• ANATOMY BASICS• SYMPTOMS• TYPES• DIAGNOSIS• TREATMENT


AS A WOMAN, YOUR CHANCE OF GETTING A PELVIC FLOOR DISORDER IS:

A. 1 in 3B. 1 in 6C. 1 in 9

Quiz“POP”

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INTRO TO PELVIC FLOOR DISORDERS

About one in three women willexperience a PFD in her

lifetimeSource: van Breda HMK, Ruud Bosch JLH, de Kort LMO. Hidden prevalence of lower urinary tract symptoms in healthy nulligravid young women. In Urogynecol J. 18 Jun 2015. [epub ahead of print]



What is the Pelvic Floor?• Set of muscles, ligaments and

connective tissue in the lowest part of the pelvis

• Supports internal organs:– Bladder– Uterus– Rectum– Vagina

• Helps control pelvic organ functioning

P E LV I C F L O O R D I S O R D E R S

Pelvic floor

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Pelvic Floor Problems• Problems with bladder and/or bowel

caused by weakened pelvic muscles or connective tissue that support the pelvic floor

• One or more symptoms:– Feeling pelvic pressure or bulge in the vagina– Urine leakage (urinary incontinence)– Overactive bladder (“gotta go”)– Difficulty emptying the bladder– Problems having a bowel movement– Gas or stool leakage (accidental bowel

incontinence)

P E LV I C F L O O R D I S O R D E R S


WHICH OF THE FOLLOWING ARE RISKS FACTOR FOR PFDS:

A. PregnancyB. AgeC. Being overweightD. SmokingE. All of the above

Quiz“POP”

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PFD RISK FACTORS

IN YOUR CONTROL

• Life style:– Don’t smoke– Maintain normal weight– Be physically active– Be cautious with extreme sports – Limit caffeine and excessive

intake of fluids– Avoid constipation

• Maintaining good health:– Keep pelvic floor healthy– Control blood sugar

LESS CONTROLLABLE

• Life stage:– Risk increases with age– Pregnancy and childbirth

• Health conditions:– Pelvic injury, pelvic surgery– Chronic lung disease– Neurological problems

URINARY INCONTINENCE (UI )

In the US,18 million women have UI

Source: Whitcomb EL, Subak LL. Effect of weight loss on urinary incontinence in women. Open Access J Urol. Aug 1 2011; 3: 123–132


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41% seek help within 1 year

Don’t Wait to Talk with Your Doctor

26% of women wait over 5 years to seek help

33% wait 1 to 5 years

U R I N A R Y I N C O N T I N E N C E

Source: Norton, P A et al. Distress and Delay Associated With Urinary Incontinence. BMJ, 297(5), November 1988


Bladder Opening

Vaginal Opening

DID YOU KNOW?The urethra and vagina are separate openings


Urinary Incontinence—Anatomy Basics

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UI—Anatomy Basics

• Your body stores urine in the bladder

• The bladder connects to a tube called the urethra

• Muscles and nerves help control the bladder and urethra

• When you go, these muscles and nerves signal the bladder to push urine out through the urethra


HOW THE BLADDER WORKS


UI—Symptoms of Control Problems

• Problems with muscles and nerves that help to hold or release urine

• UI = urinary incontinence = loss of urine

• Some have difficulty emptying bladder (trouble starting the flow of urine)


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• Strong, sudden urge just before losing urine

• Involuntary loss of both small and large amounts of urine with activities such as coughing, laughing, or straining

• Slow or interrupted urine stream or sense of incomplete bladder emptying

• Sexual problems, e.g., leaking urine with sexual activity


of UI Continued


Quiz“POP”

BLADDER CONTROL PROBLEMS ONLY OCCUR IN WOMEN AFTER MENOPAUSE

A. True.B. False.

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UI IS MORE COMMON IN OLDER WOMEN

• Up to 38% of those aged 80 or over

1 IN 4 YOUNGER WOMEN (20 ‐ 39 YEARS)

• Weight pressing on the pelvic floor(pregnancy, overweight)

• Bodybuilding and intensive weight training is a risk for both urinary and bowel incontinence

Women of All Ages Can Be Affected

Pressure on the bladder


Sources:

Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. Women. Obstet Gynecol 2014;123:141

Nygaard I, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA, 300(11), Sept. 2008

Tahereh E., et al. The Frequency of Pelvic Floor Dysfunctions and their Risk Factors in Women aged 40‐55. Journal of Family and Reproductive Health 6(2), June 2012


UI—TypesU R I N A R Y I N C O N T I N E N C E

STRESS INCONTINENCE

• Urine leaks with activities

• Coughing, sneezing, laughing, lifting, exercising

URGE INCOTINENCE Overactive Bladder

• Gotta go now” (urgency)

• “Gotta go now” with leakage (urge incontinence)

• “Gotta go often” (frequency)

• Going often during the night (nocturia)

OTHER TYPES

• Mixed incontinence (stress and urge)

• Continuous (unpredictable) incontinence

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MAKING CHANGES TO YOUR DIET MAY HELP CONTROL UI:

A. TrueB. False

Quiz“POP”


UI—Treatments• Depends on out what treatment is best for YOU:

– Ask your doctor about risks, potential complications, and follow-up care

• For most, health care providers may recommend:– Lifestyle changes– Bladder diary– Kegels (pelvic muscle exercises)

• Additional options for different types of urinary incontinence:– Stress UI—pessary, pelvic floor physical therapy, bulking therapy, surgery– Urge UI (OAB)—physical therapy, medicines, surgery

• A combination of treatments may be needed


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• Lifestyle changes:– Lose weight (if overweight)– Limit alcohol and caffeine– Avoid excess water/fluid intake

and ask you health care provider if you are drinking too much

• Bladder diary– Track of how often you go– Try to “schedule” your

bathroom trips


UI—Treatments Continued


• Lifestyle changes:– Retrain your bladder– Learn ways to control when you go– Exercise your pelvic floor muscles

and make diet changes

• Physical therapy:– Pelvic floor physical therapy– May include biofeedback techniques

• Medicines:– Bladder relaxant medicines– May need to modify dosage and/or

try different medicines


I’m Kegeling!#kegelface

Treatments-Overactive Bladder

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• Advanced Therapies—different types:– Botox® bladder injections– Peripheral tibial nerve stimulation (PTNS)– Interstim ® bladder nerve stimulator (electrical stimulator or

neuromodulator)

• Combination of treatments

Image Source: Medtronic, Inc. © 2006


Treatments-Overactive Bladder


• For many women with stress urinary incontinence (SUI), a pessary helps control leakage:─ Silicone vaginal insert─ Different shapes and sizes─ Sized to fit each patient─ Inserted into the vagina─ Supports the bladder and urethra


Treatments-Stress Urinary Incontinence

Image Source: www.MediPlus.com.uk

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• Physical therapy:─ Biofeedback─ Bladder retraining─ Pelvic floor muscle nerve stimulation─ Exercises to help strengthen and

control the pelvic floor muscles


Treatments- Stress Urinary Incontinence


• Bulking therapy:– Inject gel like material around the urethra– Tightens the neck of the bladder to prevent

urine leakage– Typically repeated every 1 to 2 years

• Outpatient or office procedure

• Lower success rate than surgery, but may help improve quality of life



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• Bladder Sling:– Sling (hammock) placed

under the urethra– Made out of native

tissue or mesh

• Aims to stop or reduce leakage

• Goal to improve quality of life




A special guest would like to share her story

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PELVIC ORGAN PROLAPSE (POP)

About half of women over 40 have some form of POP

Source: Monga A, Dobbs S. ”Pelvic Organ Prolapse” in Gynaecology by Ten Teachers, Nineteenth. CRC Press: Great Britain, 2011



Uterine ProlapseDropping of the uterus

RectoceleDropping of the posterior

vaginal wall with the rectum

CystoceleDropping of the anterior

vaginal wall with the bladder

POP—Anatomy Basics• Pelvic floor muscles and ligaments are stretched or become

too weak to hold organs in the correct position in the pelvis

• As it progresses, women can feel bulging tissue protruding through the opening of the vagina

P E LV I C O R G A N P R O L A P S E

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POP—Symptoms• Pelvic discomfort:

– Pressure and heaviness in pelvic area– Some women also experience discomfort in lower abdomen

• Bulging: – Feeling a lump in the vagina, or lump coming out of vaginal opening

• Urinary problems:– Difficulty starting to urinate– Weak or spraying stream of urine

• Bowel problems:– Chronic straining or pushing to have bowel movements



• Best treatment depends on how much symptoms bother you:– POP is not life-threatening– Treatments can help improve quality of life and sexual health

• Conservative approach:– Watch and see how things go– Dietary changes– Pelvic floor muscle exercises– Pelvic floor physical therapy

• Pessary:– Support bladder, uterus and vagina


POP—Treatments

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POP—Treatments, Surgery• Every woman's situation is different

• No single operation is right for every patient

• Specific type of surgery depends on:– Your body (anatomy)– Overall health, other health problems– Prior surgeries– Desire to retain sexual function – Experience and training of surgeon



POP—Treatments• Goals of surgery:

– Restore normal anatomy and support– Repair vaginal wall and support layers

of tissue– Reduce bulge– Improve quality of life

• Success or failure of someone else's operation should never be the deciding factor for you

• You and your doctor must decide what’s best for you


MORE ON SURGERY

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IS LIVING WITH PFDS A NORMAL PART OF AGING?

A. YesB. No

Quiz“POP”


A special guest would like to share her story

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Bowel Control

15 million U.S. women over age 40

experience accidental bowel leakage

National Institute of Diabetes and Digestive and Kidney Diseases. Fecal Incontinence, http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/index.aspx

WH‐175304‐AA. Slide 19 of 44. August 2013

• 1 in 5 women: occasional• 1 in 12 women: every month• 1 in 30 women: every week

• Less than 30% talk to a health care provider!


Don’t Be Embarrassed

• Bowel control problems can be upsetting and embarrassing.

• Don’t be ashamed to discuss with your doctor.

• Bowel control problems may be related to a medical problem.

• Bowel control problems can be treated.

Bowel Control



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How Bowel Continence Works

Bowel Control

• Muscles and nerves in the rectum and anus:─ Hold stool.─ Let you know when rectum is full.─ Signal when to release stool.

• Pelvic floor nerves and muscles work together to help with bowel and gas control.

http://www.anatomy.yalemedicine.org/Lab_10/Case_rez/case_3/m3.php

http://www.aboutgimotility.org/site/about‐gi‐motility/disorders‐of‐the‐pelvic‐floor/


Symptoms of Control Problems• Accidental loss of gas and/or bowel contents.

• Chronic constipation (4+ million people in U.S.):─ Bowel movement fewer than 2 times per week. ─ Stool is hard, dry, small, and difficult to get out. ─ Straining and bloating.─ Pain with bowel movement.

• Diarrhea:─ Loose, watery stools. ─ Passing loose stools 3 or more times per day.─ More than 2 days may signal a problem.

Bowel Control


National Institute of Diabetes and Digestive and Kidney Diseases. Constipation. http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/index.aspx


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Treatments—Diet Changes

Bowel Control

For constipation, diarrhea, and difficulty with defecation:• Increase fiber intake to 25‐35 g/day – gradually!

─ Helps both constipation and diarrhea ─ Promotes complete passage of stool─ Need to drink plenty of fluids

For accidental bowel leakage:• Avoid spicy food, caffeine, triggers

For constipation:• Avoid starch (white rice, bread, pasta)

WH‐175304‐AA. Slide 23 of 44. August 2013.


http://hookedoniron.com/home/got‐fiber


Treatments—Medicines, PT

• Medicines:– Stool softeners (soften stool)– Laxatives (make you go)– Antidiarrheals (stop you from going)

• Physical therapy (PT):– Improves the pelvic muscle strength,

tone, endurance, and coordination. – May include biofeedback.– Ask your doctor for a referral to a

specialized physical therapist.

Bowel Control


http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/index.aspx

Satish. Practice Guidelines: Diagnosis and Management of Fecal Incontinence. Am J Gastro, 2004.

http://www.babymed.com/medications/constipation‐and‐pregnancy‐there‐safe‐stool‐softener

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Treatments—Rectal Insert

Bowel Control

renew‐medical.com


Treatments—Vaginal Insert

Bowel Control

www.pelvalon.com

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Treatments—Surgery

Bowel Control

• The goal of surgery is to improve bowel function:─ Improve bowel emptying.─ Improve bowel control.─ Help with bowel emptying at appropriate times.

• Types of surgery include:─ Sphincter repair (sphincteroplasty)─ Bulking agents─ Bowel pacemaker (neuromodulator) to help

pelvic and anal sphincter muscles contract National Institute of Diabetes and Digestive and Kidney Diseases. Fecal Incontinence,

http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/index.aspx

Satish SCR. Practice Guidelines: Diagnosis and Management of Fecal Incontinence. American Journal of Gastroenterology, 2004.


Pelvic Physical Therapists in Madison

Break Free From PFDs!


UW Health

(608) 828‐6600

Research Park &

The American Center

www.uwhealth.org/orthopedic‐surgery‐

rehab/physical‐therapy‐for‐pelvic‐floor‐disorders/13428

Meriter – UnityPointHealth

(608) 417‐8250

Madison, DeForest, Middleton, Monona,

Wellness Center, West

www.unitypoint.org/madison/physical‐therapy‐for‐

women.aspx

Capitol Physical Therapy

(608) 848‐6628

Verona, Madison, Mount Horeb, Sun

Prairie, and Waunakee

Capitolphysicaltherapy.com

www.apta.org

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PFDs are not a normal part of aging

B R E A K F R E E — W W W.VO I C E S F O R P F D . O R G



You Are Not Alone

• Share stories

• Get support

• Ask experts about PFDs

• Join the dialogue @ www.VoicesforPFD.org

B R E A K F R E E — W W W.V O I C E S F O R P F D . O R G

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Thank you!

• We will now break up into groups

– Bladder Problems– Pelvic Organ Prolapse– Bowel Problems

• Please fill out the evaluations in the folder– This will help us improve these presentations!!


1. Ellerkmann RM, et al. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol, 185(6), December 2001

2. Food and Drug Administration. Information for Patients for POP, www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh

3. Gormley EA, et al. American Urological Association (AUA) Guideline: Diagnosis and Treatment of Overactive Bladder (non‐Neurogenic) in Adults: AUA/SUFU Guideline. May 2012

4. Hendrix SL, et al. Pelvic organ prolapse in the Women’s Health Initiative. Am J Obstet Gynecol 186(6), 2006

5. Lawrence, JM, et al. Prevalence and Co‐Occurrence of Pelvic Floor Disorders in Community‐Dwelling Women. Obstetrics & Gynecology. 111(3), March 2008

6. Monga A, Dobbs S. ”Pelvic Organ Prolapse” in Gynaecology by Ten Teachers, Nineteenth. CRC Press: Great Britain, 2011

7. National Institute of Child Health and Human Development. Pelvic Floor Disorders, www.nichd.nih.gov/health/topics/pelvicfloor/conditioninfo/Pages/default.aspx

8. National Institute of Diabetes and Digestive and Kidney Diseases. Urinary Incontinence in Women, kidney.niddk.nih.gov/KUDiseases/pubs/uiwomen

9. Norton, P A et al. Distress and Delay Associated With Urinary Incontinence. BMJ, 297(5), November 1988

10. Nygaard I, Barber MD, Burgio, KL, et al. Prevalence of Symptomatic Pelvic Floor Disorders in US Women. JAMA. 2008;300(11):1311‐1316

11. Olsen AL, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 89(4), 1997.Pelvic Floor Institute. Pelvic Floor Muscle Training, www.bostonscientific.com/templatedata/imports/HTML/PFI_Patient/pelvic‐floor‐patient.htm

12. Tahereh E., et al. The Frequency of Pelvic Floor Dysfunctions and their Risk Factors in Women aged 40‐55. J Family and Reproductive Health 6(2), June 2012

13. van Breda HMK, Ruud Bosch JLH, de Kort LMO. Hidden prevalence of lower urinary tract symptoms in healthy nulligravid young women. In Urogynecol J. 18 Jun 2015. [epub ahead of print]

14. Whitcomb EL, Subak LL. Effect of weight loss on urinary incontinence in women. Open Access J Urol. Aug 1 2011; 3: 123–132

15. Wu J, et al. Forecasting the Prevalence of Pelvic Floor Disorders. Obstet and Gynecol, 114 (6), December 2009

16. Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. Women. Obstet Gynecol 2014;123:141

REFERENCES

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